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tv   Dr. Ezekiel Emanuel Delivers Remarks on the Future of Health Care  CSPAN  April 19, 2017 9:30am-10:29am EDT

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>> now, university of provence till -- pennsylvania professor ezekiel emanuel talks about the future of health care and medical practices outlined in his book, prescription for the future. his remarks are part of a symposium on how kirk pepperdine university school of business. this is just over an hour. [applause] >> thank you for that introduction. am i on? it says on. there you go. it is the case that i'm going to madagascar in july working with chocolatier unlike you, you know, why try to make the world's second test anything. we always want to be the best. may not succeed, but certainly
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that's the aspiration. i want to pick up on something mentioned. i like to start all my talks about health care with a number and that number is now $3.4 trillion. $3.4 trillion. i know a lot of you are very smart. i know a lot of you had dealings in big numbers. hundreds of millions of dollars. some of you probably billions of dollars. no matter how smart you are and how big of a budget you deal with, you do not know how big $3.4 trillion art. i can say that with 100% confident because i would do the one organization in the entire world that regularly deals in trillions of dollars and not the federal government office of management and budget. that's the size of the federal budget round about. when we were there, i was very,
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very clear that no one in our office at 550 people knew how big $3.4 trillion was. that's how much the united states spent last year, 2016 on health care. now, to put that number in context, there's lots of ways is put in context how many dollars stack singly would take us how far to the mid. it turns out to be a lot further than you think. can they get the side? i like to use this context. this context. these are the world's gdp is, grossed another product. if everything was done. the united states has far and away the largest gdp in the world. china is second. japan is third. germany is for it and our health care system is just under germany. we were $3.2 trillion in 2015. next year we will overtake germany.
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our health care system will overtake germany. in other words, it will be the fourth largest economy in the entire world. their 85 million people in germany. everything they spend for this great bmws, or outbursts,, all of that stuff will spend more on health care and united states in all of germany. it's a huge amount of money. and we know two things about the american health care system, right? one, is substantially underperforms. on a per person basis, we are 27% more expensive than the next highest country. 27% marks that on a per person basis than the next highest. no one in this room believes we are getting 27% better quality
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or value or patient experience than other countries. we are probably not getting one. right? very, very substantial underperformance. a lot of you are corporate executives. when you have underperformance coming of high costs, not such high quality. you get irate. as you should. and i think we have seen over the last few years, probably 10 years the fact that the american public corporate executives. everyone is unhappy with their underperformance in our health care system. this is how bad the underperformance is. according to the who, world health organization, we come in at number 37. maybe they are wrong. i'm willing to say, you know, they're in geneva. they don't have a good bit of, whatever. maybe we are better.
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maybe we are 18. still, tremendous underperformance. and by the way, if you look at that list, there are such advanced countries such as cyprus and morocco ahead of us. it is clearly a serious, serious problem. large part of the problem is that we would say three big issues. one is we deliver a lot of unnecessary care. i second is we deliver care inefficiently in the third problem is we have crises that are simply too high for what we do. i think it was mentioned that i'm an oncologist. i train at the cancer institute and did oncology for many years. almost all of my examples are oncologic. i was trained as a medical
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oncologist. those are people who give keynote turkey you will see almost all my examples are about the other colleges, and those who do radiation and other things. i was wonder why did i go to medical oncology. they'd do it so well. they come in at 9:00, and they get paid a lot by many. where did i go wrong? but this is about oncology, and this slide to illustrate some of our problems. early-stage breast cancer, small module in the, removed. one of the things that you are not supposed to do is take a pet, ct scan, costs about $5000 in hunt for metastatic disease because it is just so unlikely to be there. slava guidelines from the radiation people talk about ict.
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this is a study by a colleague, scott ramsey, up in seattle or he went around to local clinicals and practices, but cannot how are the women with very small module breast cancer got that ct scans. the rate goes from something like 80% of the facilities and 80% of the women on some facilities at the very lowest 10% of the women getting pet ct scans. again, let me emphasize, we are not talking about government guidelines. we are talking about doctors recommending treatment based upon the data that they see don't do this. either way, how much it seeders you charge for this? cedars is one of those hospitals, probably 10,000. many other hot it is probably 5000. just a joke. that is just a joke. it's a very expensive tests.
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totally unnecessary in some facilities, 80% of the women are getting mad. lots and lots of cases like that. prices, by the way i could go on and on. radiation, oncology, lots of other examples. colonoscopy prices, we now know prices vary hugely across the country. here more than fourfold between baltimore and new york. and probably within new york city. huge variation in the price paid for the exact same procedure. and we now also have payment varies with the service is done in a hospital facility, prices substantially higher than in a physician office or outpatient facility. the relationship to quality. their relationship to reality. should be pretty uniform across the country with some variation
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for facilities and local labor costs. such are not going to get a four and a half old price difference across the country. so we have high costs, low quality, lots of unnecessary care, lots of high prices. talk to emphasize american health care has become unaffordable. one way of understanding this election is the hostility to the affordable care at his people are faced about the following dilemma. they are paying high premiums and again, i did that the bulls. and when they have to pay out of pocket is out graciously expensive. that's the definition of and affordability. president trump ran on that issue and we have to have an answer to that issue for the american public. this slide just summarizes,
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gives you three members to put the affordability and context. first is the median household income. but i remind you that medium is in case you forgot your statistics from college all those years ago. half of american households make less than this amount, half make more. we in this room are very privileged in american society. very privileged. i don't buy your intense, but i don't have to know your incomes. you're in health care at the top of the health care heap in your and very nice clothes. okay? we don't realize that the median in america is $56,000 per household. not an individual. now, the average employer-sponsored insurance premium, when pepperdine provides his professors or administrators employer-sponsored insurance across the country 2016, the average premium all in. the employer contribution and
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the economists will tell you they are all the employee contributions, but we won't go into that now. it's $18,000. the median income in america's $56,000. one third as health insurance premiums. i don't know, is that unaffordable to you? it sounds outrageous to me. and as was mentioned, we are now on a per capita health care spending of $10,000 is the number to keeping your head if you want to be precise. $9990. that is on a per capita basis. obviously if they like to tell my students that worked, health care spending is not late enough better. it not evenly spread. it is lumpy, bumpy. older people spend more, younger people ask him population will spend virtually nothing. but the average is that thousand dollars. this is the definition of an affordability.
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and it has to and i believe will be solved. one of the things we've seen over over the last eight to 10 years to 17.5, 18%, that's it. that's what the country can afford in health care. not a dime more. we have to get health care spending price at zero. that is our goal. i think we can get it. what is the way forward? well, i have said the last three or four years going around to look at places that are doing really, really well. they are delivering high-value care. they've got high quality, relatively low cost and good patient experience. i will be perfectly honest with you, probably be an embarrassment to my work colleagues. i wasn't systematic about this.
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i don't know how many of you have read jim collins book from gray to gray, which is a superb book. he spent months and months studying companies before he picked his sanity went to look at. he looked at their stock prices compared to other stock prices and all sorts of stuff. he did it very scientifically. he wrote a brilliant type of book. a lot of lessons for people and not people and not for people and not-for-profit as well as the for-profit center but unfortunately a debt of 10 companies fell out of the top tier almost immediately. i was much more have passed. i have heard about places that were doing great and i went to visit them. as giving speeches and someone tells me we are doing stuff grade and i went and visited and saw what they are doing. all around the country. part of my goal is to differentiate the signal from the noe. it is very hard for the public good for you for most of us in
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health care to see lots of beacons. they are small at the moment. they are not necessarily at the places you have heard of. but they're all over. and i think over the next five to 10 years, they are going to coalesce ever going to have really fantastic performing health care. now i am, as someone might say, a congenital optimist. things are going to get better. and one of the things that's always good to come out to california because one of the aims that i think is really, really clear is that coming in now, americans are incredibly dynamic, inventive, innovative people. when we put our mind to it, we can go from 37th in the country to number one. the reason it's good to be in california is because you guys
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prove it and wine. a lot of you i can see grew up when i grew up in our big wine with gallo. and now we just not everyone in the world out with their fantastic wine. grape california, oregon wines are the best in the world. no one has any disagreement that we are in the super top tier. we are doing the same day and olive oil, mainly in california. you can feel this good stuff. i really do like food i know it doesn't show, but i really do like food. we do it in chocolate. we are doing a cover when we put our mind to it, we are the best. we cannot get out of the park. it takes time to grow and bottle it right, it better.
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but in health care is going to be the same. we are now super focused on health care and country and we are going to do it. i've gotten around to a number of places. things have really transformed. i want to take you on a journey by talking about ms. harris. she has a number of chronic conditions, no surprise to you. very bad congestive heart failure. she's walking with a walk around her apartment, just a few steps exhausted her. and i went to visit her, she was sitting in the chair, it's tv screenplay gospel music, working through some puzzle books. she also has that hypertension. bad renal failure. not on this, but it's pretty bad. two years ago she was living independently at 93, though she
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was visiting her sister's house and she had an episode aired she felt to the floor, last conscious mess. her sister called the ambulance. they've ushered to a hospital about 1.5 miles from the house. they determined she wasn't having a stroke. she wasn't having a heart attack or the like she had the syndrome and enter to an affiliated hospital with a cardiologist there put in an automatic implantable defibrillator into her heart. maybe there is a cardiologist in the room. we could probably have unnecessary care to donate cardia deferred to later. nevertheless, she got it. .com, has been living with her sister for the last two years. her sister is a very vigorous now 93-year-old, but a few months ago that type us with gastric cancer and that is
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taking its toll. she's pretty limited to the house but she is a nurse visiting her ever since she got her defibrillator implanted, sets out her medicines, make sure she takes the medicine. she is totally, totally classic american fragmented care. a primary care doc or who fortunately comes to her house for primary care so she doesn't have to go out. when i was visiting her, but she had a stack of cards with physician appointments. so the week i was visiting her, she had to go to the enough i'll are just care of her and she had to get some blood and tests before that. it's a big rigmarole for her to go to the doc heard because she has to find someone in the neighborhood who as a car. she has to pay the two take off work.
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when she gets to the hospital, she has to go to three different places and even methodologist, check in, go to the lab, go to a third place and see the nephrologists. the week after she's the her enough ologies she had to go to the cardiologist in about a month later she has to go to her at their regular cardiologist. she has that they mentioned a visiting nurse bank only. no coordination among them. they don't talk about nato powwow how they are going to manager. they don't talk what's necessary to make sure they are not duplicating tests. fortunately, a few months before, but six months before i saw her, her manager and explained that none had identified her as high risk and had begun a service with the
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spire and i actually happen to be visiting with her pileated care nurse, mckenzie. the mckenzie began to see her, mckenzie to occur through a pulse, which is basically a souped-up dmr for what would happen if she emerge l.a. had a cardiac arrest or stroke your she also took her to an insecure directive and we were sitting at her dining room table where the picture was taken in the pulse and advanced directive or read on the dining room table. should we put it any favors? no, it's right here in case anything goes wrong. so it's available. she's pretty clear about her wishes. she's as i've always been in a 10 minute, always the one helping everyone else. now i can't do nothing for myself it had been ready ever since i had my heart attack, whenever that the board is ready
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to do his work. fisher watt resuscitation? no. did she want to be on the defibrillator? no. did she want dialysis? no. issue on surgery? no. she want to to be in the intensive care unit? no. and and a she's going to enough ologies. she's got this defibrillator. why is there a defibrillator they are not turned off because you don't want to be resuscitated. classic, uncoordinated, fragmented health care in the united states. that little defibrillator, i know why i asked. mayo, is your price cheaper? this is not optimal care. classic fragmented uncoordinated care and she's at home. so as i've said, i've gone around to numerous places
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looking at what they do. i have identified 12 transformational practices. these are practices, places that are really knocking it out of the park. high quality, low cost and good patient experience are doing. importantly, i want to say two things. not every place is doing all of them. sometimes they do one or two. even the best places that have really been doing transfer and karen high-value care for several decades are not doing them all. no place i went to purdue in all 12 peers to be that great places. there's still plenty of room for improvement, which is one of the things that makes me very, very optimistic. he begins his schedule in the first with patients. how do you change the scheduling that they places. there are two keys.
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take it away from the doctors. they should not be in control. they do a crummy job of it. and second, you need open access scheduling, which means that the start of any day, somewhere between 20 and some experts say 70% of appointment are empty and i'll talk about why that's important. i didn't think about scheduling a been key to transformation. the name and registration, go in and of you are. what is one of the most annoying experiences you have any go to the doctor or hospital for a laugh test? you've got to feel out that gd form again by hand, asking if you have any thyroid problems, lung disease. what are your allergies? i can tell you the number of
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times i filled out that form over and or and over again. why? changing it to make it much better at eliminating duplicate records which cost a fortune and many other things. thing is no surprise about nowhere remained a little experience of going from the waiting room to the exam room, places that have transformed care have made that super high value. just that little wall. completely changed the care for patients. this performance measurement and reporting back not just doctors but a medical assistant nurse practitioners. standardization of care. the book is filled with stories of people going to two doctors missing practice getting two different levels of care, two different exams and recommendations where they should be the exact same. chronic care coordination i will talk about in a second. the ministry is firm and provider interactions. shared decision-making.
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is a decision made for things like hip replacement, knee replacements, arthritis or stand, placement. the site of service turns out to be critical, which specialists interact with under what conditions, which hospital to refer people to, rehab facilities. the institutionalization. i predicted in my book reinventing health care we are going to get rid of a thousand hospitals. we're taking care of the four walls of the institutions and delivering another facilities, big, big part of the transformation. we should not be in facilities. some of you are old enough to remember the backlash against managed care in the 1990s. one was people being upset about the drive-through deliveries, the 48 hours days. now no one do you stay in the hospital after delivery is a
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good thing. only badness can happen to you. infection or fall or some thing. that psychology from a medical solution. not great places. they are not coming to marina del rey and relaxing on the beach are going to pepperdine and relaxing -- no, i didn't say that. and then there's expanding the scope of behavioral health care intervention, something often filed away to medical care. payload of care like mckenzie. community interventions for lower income individuals with social networks and lifestyle interventions. exercise, diet, interventions. the book goes through all this while. i don't have time to do that with you. i'm going to talk about chronic care coronation. let me begin with reminding you of some of the data. medicare patients who have five chronic illnesses and their are
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a lot of fun on average of 14 different decisions. talk about fragmented care. ms. harris is a classic example. just for chronic conditions, four different doctors, to visiting nurses and no coordination. half of the medicare population is on fiber wardrobes. and we know from data, very few of them take their drugs correctly. you write a prescription as a doctor, what's the chances that patients will actually fill it? 70%. but really come you came to the doctor. he wanted my help. i gave you the prescription and you'll miss that 70% of the time. when patients are surveyed, only 70% of the time might be taking drugs correctly either every day with a full 10 days of the antibiotics or whatever it is.
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multiply .7 by .7 and half the time people are taking drugs properly. not doing it. we know there's plenty of good data that when patients are noncompliant, much higher chance they will end up in the emergency room hospitalized or even dead. 5.4 fold hypertension and are taking an compliant and middle end up with one of those three outcomes. was the biggest headache for practicing physicians? noncompliance with physicians and recommendations. the single thing that is most frustrating to them. now, the thing that patient. noncompliance. their fault. well, try and take five pills a day can be a problem. if you're trying to remember what you're supposed to do and live a normal life. places have solved this problem.
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rgb aco is the rio grande valley. i'm taking it down to the furthest tip in texas. most of the population there are mexican-americans. 45% of the adult population has diabetes. many people do not speak english. it was lampooned in "the new yorker" in the 2009 site about health care reform by two of the one d. is the place where the highest per capita cost of medicare and the country. ..
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superexpensive. well, they set up the program, and the rio grande valley aco is a collection of four practices that managed a lot of medicare patients. they now manage her in entirely different way. they have at each one of the clinics i went, talked with, they have for sites and each one of the sites they have a coordinator who works with patients. on-site, co-located working with the doctors. they take over patients like this. the doctor personally introduces the patient to the chronic care coordinator. they come in to see that the doctor or the chronic care court
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nader every two or three weeks. when they come in if their diabetic they get a rapid -- able to do in five minutes. they discuss the meaning of that. they talk about the diet, they have a dietitian who is they are, educates patients about eat, how to read labels on can so it's appropriate for them. they also have instituted a policy that -- that is call or. call us if there some problem. don't call the ambulance. or better yet, come in and they'll change their schedule. open access schedule. one-third of their slots in the morning are empty for people who can come in and be seen that very day. all right?
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the ceo of what other southern california plants that does a great job, they work with frail elderly, it's a medicare advantage plan, care more. they were bought a number of years ago by anthem which is a singularly nothing with them so far. he says let's face it, chronic care management is not rocket science. it's measuring lab values, engaging patients, entering medication adherence, supporting them in doing the right behaviors. that requires time. i would also say requires face-to-face contact. requires a relationship with people. you go to these places over and over again and you see that they all follow the same. when you do this research, it's looking at places and trying to dissect what they're doing. and you do this there's a term that you know yet hit pay dirt. it's called saturation. you heard a story from the rio grande aco. you then go to another place,
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the clinic in madison, wisconsin, and it's like this is a bad rerun. i've heard the story over and over again. that's called saturation. five things that everyone does. identify high-risk patients. it turns out most of them don't want complex algorithms, predictive algorithms, ask the doctors and nurses can write? bane of either high risk high cost patients are. they don't know all of them but they know a lot of them. and everyone does it the same. medical intuition. then they run a predictive algorithm and today they run that for? those patients who are high cost high risk but are not coming into the clinic. the 20% who are invisible. that part of the population that simply goes to the emergency room and never make it to the office. but between intuition and some good but not very sophisticated doesn't have to be for a sophisticated predictive algorithm you can identify a lot of your high cost high risk
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patients. second step, and bed chronic care coordinators and managers in the practice. and by the way this isn't only for primary care. works also for medical oncology, cardiology, lots of practitioners we see patient over and over because they get unstable. pulmonary with copd patients. this notion of embedding the coordinator in the practice is critical. this is why i believe, having insurance companies have chronic care coordinator zocalo patients, never works. no relationships. no relationship between the care coordinator and doctors are there all on the simply picked the relationship between the chronic care coordinator and the patient with the trust by the patient that this person is really working with the doctor. colocation, physical location location i think is critical. third, constant touching. every two or three weeks they come in. same thing at care more.
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come in, talk to them. one of the interesting things camera does what diabetic patients is it has a toenail clipping clinic. why? two reasons. a lot of people with diabetes can't feel their toes. that cat, they can get a load come not feel that i have an open sore, gets infected, gets gangrene, and petition. a lot of money. so one is preventative. the other is you are engaging the patient. you might not know this but i have a daughter who work with boston healthcare for the homeless and one of the things she did was to cut the toenails of homeless people. you could into an amazing conversation with people. a good opportunity to educate white toenails are important. why eating is important for diabetics. lots of high touch care. that's one example of repeated interactions that they have. number four, empower these chronic care managers, chronic
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and coordinator to close care gaps to one of the things doctor saint is now the responsible for ordering that mammogram, that flu vaccine, the pap smear and all the measures. you take it off the doctor and the chronic care coordinator or the medical assistant, they are responsible for doing these cup closing his care gaps for high-risk patients. and last can use frequent contacts to ensure compliance and adherence with care goals. this is how you make sure that patients are taking medication, weighing themselves in the morning, calling it there seems to be a problem, making sure that the medications are refilled, they are not skipping. it can be in the office once you have a relationship, it can be telephonically. picnicking by -- it can even be by tex. these five steps are done everywhere. again, our number one complaint
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is that patients are from us too much for trying to streamline the calls. but when patient begin that my doctors actually contacting me, doesn't wait for me to come in, and it's happening a lot, that's probably you are right at the tipping point. that is a good place to be with chronic care coordination. how good is a place like care more? well, care more has as i mentioned frail elderly, the risk score under medicare patients is 1.08 where is the normal medicare is 1.0. they have a measure of hospital admissions, their bed days are 1009, from 1000 medical patients patients. the average in california is 1800. in southern california with the practice it's 2200.
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they are knocking it out of the park. when i was there the 80,000 elderly enrolled in a medicare advantage plan. they had 211 in the hospital. if you're in a hospital you get out quick. they have many other practices. you meet your care in the hospital. they follow you out to your home. you can get phenomenal results. their practice is about 20% lower cost than, per patient vendor competition. the second area want to talk about is behavioral health. you know, we have for decades in this country behavior health. psychiatrists don't interact with the rest of the healthcare system. they do their things. they have their own records. they don't practice in the same
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facilities. and we know behavioral health is a huge problem in this country. if you systematically assessed hospitalized patients in general medical wards or outpatients, 30% have undiagnosed behavioral health problems. depression, anxiety, alcohol abuse, substance abuse of other sorts. not to mention the severe schizophrenia, bipolar disorders. 30%. we also know that over all if you look at the total health care spent in this country, behavioral health, again depression, anxiety, severe psychiatric problems, substance abuse, fourth biggest bucket of spent in our country, fourth, $187 billion behavioral health. this is part of it. i'm not talking about people whose main problem is behavior
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health. i'm talking about people who have physical problems, chronic illness, congestive heart kelly, cancer. those with comorbid mental health problems, super expensive as this slide shows, on a per month basis if you have just a regular old chronic illness, you are at whatever that number is, $860. if you have a comorbid mental health condition, you are more than 50% more expensive. mental health problems add to managing chronic illness. that's a vicious cycle. you've got diabetes and managing is complex. you get depressed when you get anxious. because you're depressed you don't manage your diabetes so well, you eat, you bench. the diabetes go out of control. you need more healthcare services. you are back in it, you get
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depressed again. or, and i knew this was true and i was practicing cancer care with a lot of my patients, they were highly anxious and is maquette you coming back? every twist it would run to the emergency room. is it back? why they want that ct scan and indeed it for reassurance or they would be very anxious and be accessing the healthcare system in different ways. very important to treat this mental health conditions. we are now i would say unlike chronic care where we have good models, across the country, well-established with those same five practices we are in the early stages of doing better behavioral health interventions. and most places are experimenting. i can't tell you there's a a proven defensive model but there are some that are better practice it better experiments with new things.
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so let me tell you about caremore, just as one example. their experience was if they give the patient referral to a community based psychiatrist or either depression or anxiety or some other mental health problem, right, they might get an appointment in two to three months, if they are lucky. they changed their practice. so when a person signs up for care what they get a healthy start exam by a nurse practitioner, part of which is screening for mental health conditions. if the screen positive, like on for a society, or ph 29, they have a social worker, a psychologist and if they needed because there's cognitive impairment or some other impairment from the mental health issue they have a lawyer help them. and they see patients within 48 hours. very approach
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isn't only for big plans. we went to hawaii and talk to a group of, small group central medical clinic, 15 primary care doctors, nine primary care doctors, pediatricians, couple surgeons, a couple of obese, 15 altogether. and about four years ago they had some psychologists and social workers rent office from them two and half days a week. they would refer patients who they thought needed it. now they are up to four full days a week with him in office. they are collated -- co-located physically but they're using different medical records still. telling severally, not financially merged but they are co-located. it's basically taking the chronic care model and moving it
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to behavioral health. that's one approach. the central medical clinic in hawaii isn't the only one doing that. we visited in chicago advocate healthcare which is a group, very large group, a 6300 affiliated hundred affiliated doctors and they're doing the same kind of thing, which is in the big practices they are collated psychologists and social workers to take care of patients and sis medical screening patients for anxiety and depression and in referring them to it. the chronic care model. it's also an adaptation of collaborative care which is an older model that was pioneered out of the university of washington in seattle, and it works. there's some very good data. you focus in on targeted interventions to take up whatever the problem is, whatever is really pushing the patient off.
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you work towards a resolution and three to six months. you can bring those asked a cost associated with behavior health down, improve care for the patient. now, co-location can work. this is a quote from the doctor at the central medical clinic in hawaii. he says, talk about a woman who came into them with postpartum depression and was suicidal. answered what did your family brought her back in to the clinic. she insisted she never see a psychiatrist. at the end to his appointment, he's a primary care doctor come with the patient i asked her to accompany me down the hall. i didn't introduce her to those who work in office, not merge but works in office. right then he began seeing her. the family describes this as literally they think this saved her life from suicide. now, colocation, there there are people who believe it cannot be scaled. there are not enough people
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willing to become social workers and psychologist willing to be co-located. one of the companies i work with is quartet. so it's a conflict of interest. i'm going to tell you about them but have some financial arrangements with them. they have a platform, a virtual platform where the identify social workers, psychologists who work schedules in private practices and a link them up to primary care appointments. when a patient screen positive that primary care doctor refers event. they didn't screen the patient online with screening techniques. they then identify psychologists or social workers who are near the patient. they also asked the patient which way do want to be treated. did he want face-to-face visits, virtual interaction over a skype connection?
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and they also measure the progress of the social worker or the psychiatris psychologist tos resolving the psychological problem of the patient. so they're trying to establish performance measures for their team of people. it is helpful, they also interface with the patient to make sure they keep appointments. one of the big problems you might imagine in mental health and behaviors face, missing appointments. they have various techniques to work with patients to make sure that they show up. early days, told been around a few years, not proven yet but they're beginning to establish it. other groups use virtual medicine. so kaiser permanente mid-atlantic in the washington maryland and virginia area has a psychologist at a station that can visually interact with patients. they think this is very good for patients who have agoraphobia, fear of socials situations or
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depressed, can't get themselves out of the house. they interact virtually and provide virtual therapy both on emergency basis and even on an ongoing basis. as i say these are early days in the behavior health space, but the most places that have transformed and really taken, i won't say solve but really a bt on the chronic care management, this is the next big area. why? because chronic care management you can squeeze about 20% of your costs out if you do chronic care management by reducing emergency room, keeping patients healthy. but that's probably the limit of what you can squeeze out. then you need to go to the next thing, and the next thing is behavioral health. i think we will have real focus on that over the next five or ten years. well, as i say there are 12 12 transformational practices. i am just giving you a dive into
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two of them, but there are good stories in good examples in all 12 and as i say, some of them are more experimental like behavioral health, places have done a good job with kennedy interventions, places of the denigratdone a great job on pere management or standardization. a book as was mentioned is coming out in june and it covers all 12 in-depth and addresses the question of whether these can be adapted. i actually also think, and i'm going to conclude with this point, these transmission practices can be very, very important for patients who are trying to select doctors and select the right practices and want to go to the best practices. they allow you to ask very focused questions that will differentiate really good practices from not so good practices. that's one place a lot of these examples were using, and then we
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have, not developing anymore, online education programming for practitioners that balances out this what i've learnt in the transformation, we haven't online masters for people who really want to go deep and want to get leadership in sort of new value-based programming. healthcare, a masters in healthcare innovation. we also have focused certificates and look at how to transform practices by looking at the policy issues, a behavioral economics that underlies healthcare, process improvement, assessing changed to make sure you are moving in the right direction. all of those things are available now. i want to thank you very much and look forward to your questions. [applause] >> thank you so much. great information here we're
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going to open it up to questions for dr. emanuel. there are volunteers around the room with microphones, if you would just raise your hand and they will find you. to get us started, one of the things i wanted to ask come in your prior book you gave a great deal of good information but you spoke about impediments they need to be overcome to implement them. and these tall practices what you think i'd impediments people have to overcome to do that implementation? >> one of the chapters in the book talks about what other management ecosystem elements you need to be able to transform your care. i think there are probably certain things which are absolutely absolutely necessary. it's hard to transform without a leader who is like this is the direction we're going. going to value-based care, and wakes up in the morning trying to figure out all right, what we need to do?
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watch the strategic plan? what are the tactical things we need to? so that has to be some leader. i said second thing is it's impossible to do this without some data. data is one of those things where everyone in healthcare says we don't have good enough data. i don't agree with that. if that was true in the 1990s, we didn't have good enough data. that's one of the reasons it failed in the 1990s. today we do have good enough data. we can always have better data, more real-time data, or clinical relevant data but good claims data, good pharmacy data, good lab data. those are essential, but everyplace should be able to get that. i think probably in my view the weakest link on the data that we have now is sort of hospital admissions.
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so i think leadership, data absolute essential. many, many of the places i went to had what i like to call and your death experience. they had a crisis. it's literally labeled the crisis where they're going to go out of business if they didn't transform themselves. because to get everyone on board, the doctors, nurses, administrators to go in a high-value direction you need someone, you begin to think it's more threatening to our existence if we continue on old road than if we shift to the new road. usually that requires some confrontation existential threat. then a bunch of other things which i think are probably important, whether they are necessary. there's the finances pick you need to be able to make money transforming, the force of it is
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not going a good arrangement. you can do on fee-for-service. there are places, i mention wes met in new york mostly their fee-for-service come they negotiate really hard to get good rates and their ceo told me we get paid the most hour deliveries. i was like wow, why did they pay a lot for deliveries? he said it's not about the delivery. it's about the neonatal intensive care unit days and we are very low neonatal intensive care unit days and we try to deliver no one before 39 weeks. we work hard at that and our rates are low and so they're willing to pay us a lot for our maternity care. so they worked that. obviously, obviously. many other places i looked at were either medicare advantage plans, they had some capitation arrangement like kaiser permanente come there and i capitation because they are both the insurer and the provider.
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so you need some financial arrangement that allows you to make money by doing high-value care. lots of insurers are not open to a has i would say before the aca got past, just wasn't happening. different places also are looking at how to pray to doctors or administrators differently. again this is one of those areas where we are in the infancy. we don't have -- it's one of the thinks my research groups works on intensively is how do we pay doctors to believe, how do we combine incentives, financial as well as nonfinancial so those measurements with some very interesting experiments in trying to get those better for doctors, give them actionable data, tell them how they're doing compared to others. there is this ecosystem that's necessary but i think increasingly across the country using that ecosystem available in lots of different places. >> it certainly is necessary for susan to change that people have to decide to do something
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different. >> totally. >> questions? over here. >> you didn't talk a lot today about drug prices bu but i knowu have in the past. are you talking to president donald trump about potential solutions and what do you expect him to do, if anything? >> i'm sure the president can talk for himself. i know that. and he has made quite clear that drug prices are one of those things that he thinks are outrageously high, and need to come down. and i can't i think without reaching any -- breaching any confidentiality said that he is mentioned those to me, and he doesn't think he can bring down drug prices and that is on his agenda. i think that's very, very clear. >> other questions?
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>> you mention a lot of great ideas, and it would add that the impact of terror management and new behavior health interventions and everything that you listed, we are probably looking at a very small percentage of all health care spent going to those channels right now. what's it going to take this skill goes up and have those initiatives really penetrate the landscape at large? >> i think it's got to be this positive feedback loop. first of all i do think that if you look at this series of things that i recommend, places that have introduced it, introduced many of them, not all of them. as i said, knowing as a way to introduce all of them but many of them -- >> we believe this discussion at this point. you can see it in its entirety at our website at c-span.org. go and live to philadelphia for a ceremony marking the opening of the museum of the american revolution.

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